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Extrapleural Pneumonectomy (EPP)

Extrapleural pneumonectomy (EPP) is a surgical procedure that has been proven to help pleural mesothelioma patients increase their life expectancy by removing all visible signs of cancer from the chest cavity, including the affected lung. Learn more about the benefits of this procedure, risks and recovery times, and how Mesothelioma Hope can connect you with a skilled surgeon for treatment.

Medically reviewed by: Mark Levin, MD

Last updated:

What Is an Extrapleural Pneumonectomy for Mesothelioma?

An extrapleural pneumonectomy is a surgery for pleural mesothelioma that may be used when the cancer has spread beyond lining of the lung and chest wall into the lung itself.

During an EPP, the surgeon removes the affected lung, the pleura (lung lining), and parts of the pericardium (heart lining) and diaphragm (the muscle just below the lungs and heart). The goal is to cut out as much of the cancerous tissue as possible to improve the patient’s overall survival and life expectancy.

An EPP is most effective when combined with radiation and chemotherapy. According to a 2022 article published in Translational Lung Cancer Research, patients treated with an EPP, chemotherapy, and radiation therapy had a median survival of 26.8 months. Patients who had chemotherapy and surgery survived an average of 14.6 months.

Key Facts on EPP Surgery

  • Types of cancer treated: Pleural mesothelioma (cancer of the lung lining) and lung cancer
  • Eligibility criteria: Patients with localized cancer in the pleura, lung, and surrounding tissues in the chest cavity
  • Potential complications: Blood clots, infection, internal bleeding, pneumonia, and respiratory failure
  • Recovery time: Up to 2 weeks in the hospital and 6-8 weeks at home
  • Extrapleural pneumonectomy survival rate: 21% of patients are still alive after 2 years with EPP and radiation

Because an extrapleural pneumonectomy is considered major surgery, it’s usually performed at large cancer centers by surgeons who specialize in pleural mesothelioma.

Mesothelioma Hope can help you find surgeons who have many years of experience performing EPPs. Sign up for our Free Doctor Match program to get started.

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Benefits of an EPP for Mesothelioma Patients

Extrapleural pneumonectomy surgery offers many possible benefits for pleural mesothelioma patients.

The main advantages of an EPP for mesothelioma include:

  • Longer life expectancy. EPP surgery may help you live longer, especially if you also receive chemotherapy and/or radiation as part of what’s called multimodal therapy.
  • Prevention of cancer spread. An EPP can prevent the spread of cancer beyond the chest cavity, lowering the risk of harm to distant organs.
  • Removal of cancerous tissue. Taking out the entire affected lung allows more cancer to be removed from your chest cavity.
  • Symptom relief. This surgery can provide symptom relief by relieving pressure on the respiratory system and addressing issues like coughing, chest tightness, and shortness of breath.

You can learn more about the benefits of this surgery and whether you’re eligible by making an appointment with a mesothelioma doctor. Call our team at (866) 608-8933 to get help finding the right doctor and scheduling a consultation.

Extrapleural Pneumonectomy vs. Pleurectomy With Decortication

Besides an EPP, doctors may use a different surgery called pleurectomy with decortication (P/D) to treat pleural mesothelioma. Unlike an EPP, P/D surgery leaves the cancerous lung in place while tumors are removed from the pleura and chest wall.

P/D surgery is generally considered safer than an EPP since it’s less aggressive and has a shorter recovery period. Patients also live longer on average when treated with a P/D than an EPP, according to a 2021 Journal of Thoracic Disease report.

However, some thoracic surgeons believe that leaving the lung intact has certain disadvantages, including the inability to remove all tumors and a higher risk of the cancer returning.

“Extrapleural pneumonectomy was a drastic operation, but it gave the surgeons the satisfaction of knowing that everything was removed. . . . Our longest survivor just texted me 3 months ago — 25 years and counting.”

- Quote from Dr. Raphael Bueno, Thoracic Surgeon and Research Director of the International Mesothelioma Program

Some mesothelioma specialists favor P/D over EPP for patients who are older and can’t tolerate the longer healing time and potential complications.

Am I Eligible to Get an Extrapleural Pneumonectomy?

You may be eligible for an extrapleural pneumonectomy if you have:

  • A pleural mesothelioma diagnosis
  • Healthy heart and lung function
  • Cancer that hasn’t spread beyond the chest cavity

You must be in good overall health to undergo an extrapleural pneumonectomy. If you have other health problems like serious heart valve disease or pulmonary hypertension (high blood pressure in the arteries of the lungs), your doctor may recommend another type of mesothelioma treatment.

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EPP Mesothelioma Surgery Procedure

The specific steps for an EPP can vary depending on the surgeon performing the procedure and the extent of your cancer.

Here’s how the procedure usually goes:

  1. Surgery prep: You’ll receive general anesthesia to make sure you’re unconscious and don’t feel any pain during the surgery.
  2. Chest incision: Your surgeon will make a large incision (cut) on the side or front of your chest. This will give them room to access the chest cavity and remove all of the cancerous tissue.
  3. Dissection of the pleura, pericardium, and diaphragm: The inner and outer layers of the pleura will be carefully removed along with the cancerous portions of the heart lining and diaphragm.
  4. Lung removal (pneumonectomy): Your surgeon will take out the cancerous lung from the chest cavity.
  5. Diaphragm reconstruction: The surgical team will use patches, muscle flaps, or other types of synthetic materials to rebuild your diaphragm.

After surgery, you’ll be closely monitored in the intensive care unit (ICU) before you’re moved to a regular hospital room.

Illustration of an xtrapleural pneumonectomy with the patient's left lung removed along with the pericardium and a small piece of the diaphragm
An extrapleural pneumonectomy removes the affected lung, the lining of the lung, the diaphragm, and the lining of the heart to treat pleural mesothelioma.

How Does an Extrapleural Pneumonectomy Treat Mesothelioma?

EPP surgery treats mesothelioma by removing all cancerous tissue from the chest cavity.

The main purpose of an extrapleural pneumonectomy is to target the cancer before it spreads beyond the lung. This involves strategically removing the affected lung to remove cancer cells and potentially keep the disease from getting worse.

While EPP is an important surgical treatment of pleural mesothelioma, it’s most effective when used as part of multimodality therapy.

Combining the surgery with adjuvant therapies (treatments given after the main treatment) is the best way to ensure that no cancerous cells remain.


During EPP, surgeons may deliver chemotherapy directly to the chest cavity in a procedure known as hyperthermic intrathoracic chemotherapy (HITHOC). Chemotherapy drugs are added to a heated saltwater solution with the goal of killing any remaining cancer cells. The chemotherapy solution is then removed, and the surgical incision is closed.

Extrapleural Pneumonectomy Complications

As you recover from an extrapleural pneumonectomy, it’s important to know about common complications that might come up. Being aware of these potential issues will help you and your caregivers manage any problems early on.

EPP complications may include:

  • Blood clots
  • Changes in heart rhythm
  • Chest fluid buildup (pleural effusion)
  • Infections
  • Internal bleeding
  • Pneumonia
  • Respiratory failure

Your mesothelioma doctor will explain the potential risks, complications, and benefits of an EPP in greater detail before the procedure. Download our Free Checklist of Questions to Ask Your Doctor so you know what to expect.

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Extrapleural Pneumonectomy Recovery

It generally takes up to 2 weeks in the hospital and 6-8 weeks at home to regain your strength and adapt to changes in your lung function.

During this period, you may feel pain or soreness and have shortness of breath. It’s essential to follow your doctor’s recommendations for a healthy recovery.

These may include:

  • Doing breathing exercises
  • Getting pulmonary rehabilitation
  • Making lifestyle adjustments to optimize your lung function
Can I still breathe with one lung?

Yes. After EPP surgery, the remaining lung will expand and take over the work of the removed lung to ensure you can still breathe effectively.

However, having one lung may bring some changes to your daily life, so it’s important to be mindful of your activity level and make any changes your doctor recommends.

You’ll attend regular follow-up appointments where your doctor will monitor your lung function and address any side effects or complications.

While living with one lung is possible, you should maintain a healthy lifestyle after an extrapleural pneumonectomy. This includes getting plenty of rest, avoiding strenuous activity, and staying away from respiratory irritants like dust, secondhand smoke, and heavily fragranced cleaning products.

Find Doctors for EPP Mesothelioma Surgery

If you or a loved one has been diagnosed with pleural mesothelioma, extrapleural pneumonectomy surgery may help improve your prognosis and quality of life.

Mesothelioma Hope can help you schedule a consultation with an experienced specialist to see if you’re a good candidate for an EPP.

Call us now at (866) 608-8933 or use our Free Doctor Match to get connected with top thoracic surgeons in your area.

EPP for Mesothelioma FAQs

What is removed during an extrapleural pneumonectomy?

During an extrapleural pneumonectomy (EPP), surgeons remove:

  • The lung nearest to cancer tumors
  • The pleura (lung lining)
  • The diaphragm (the muscle under the lungs)
  • Part or all of the pericardium (the sac around the heart), if needed

A mesothelioma doctor can help you decide if an EPP for mesothelioma is right for you based on your overall health and the extent of your cancer.

What is the difference between a pleurectomy with decortication and an extrapleural pneumonectomy?

A pleurectomy with decortication (P/D) and an extrapleural pneumonectomy (EPP) are both surgeries used in the treatment of malignant pleural mesothelioma, but there are key differences between the two.

  • In a P/D, only the cancerous pleura (lung lining) is removed, preserving the lung and potentially leading to a quicker recovery.
  • An EPP involves the removal of the entire lung along with both layers of the pleura. This allows more of the cancer to be removed, but it may impact your lung capacity and make recovery more challenging.

A doctor can help determine which mesothelioma surgery is best in your case after considering your overall health, cancer stage, and other factors.

What are the steps for an extrapleural pneumonectomy?

Generally speaking, an EPP for mesothelioma consists of the following steps:

  1. General anesthesia: You’ll be given a general anesthetic before the procedure begins so you won’t be awake or feel any pain.
  2. Surgery begins: Your surgeon will make an incision (cut) at the front (sternotomy) or side (thoracotomy) of the chest.
  3. Removal of cancerous lung and tissue: The surgeon will then remove the diseased lung, pleura, and parts of the pericardium and diaphragm. They may also remove nearby lymph nodes if they contain visible cancer.
  4. Recovery: You can expect to spend roughly 2 weeks in the hospital. Once you’re home, it may take 6-8 weeks to fully heal and return to your normal routine.

What is the most common complication of an extrapleural pneumonectomy?

The most common complications of an EPP for mesothelioma are related to breathing and respiratory function.

Potential complications include:

  • Difficulty breathing
  • Pneumonia
  • Respiratory failure

Your medical team will do everything possible to help minimize the risk of complications from EPP surgery.

Dr. Mark LevinReviewed by:Mark Levin, MD

Certified Oncologist and Hematologist

  • Fact-Checked
  • Editor

Mark Levin, MD, has over 30 years of experience in academic and community hematology and oncology. In addition to serving as Chief or Director at four different teaching institutions throughout his life, he is still a practicing clinician, has taught and designed formal education programs, and has authored numerous publications in various fields related to hematology and oncology.

Dr. Mark Levin is an independently paid medical reviewer.

  • Board Certified Oncologist
  • 30+ Years Experience
  • Published Medical Author
Jenna TozziWritten by:

Director of Patient Advocacy

Jenna Tozzi, RN, is the Director of Patient Advocacy at Mesothelioma Hope. With more than 15 years of experience as an adult and pediatric oncology nurse navigator, Jenna provides exceptional guidance and support to mesothelioma patients and their loved ones. Jenna has been featured in Oncology Nursing News and is a member of the Academy of Oncology Nurse & Patient Navigators & the American Nurses Association.

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  1. American Cancer Society. (n.d.) Surgery for Malignant Mesothelioma. Retrieved May 23, 2024, from
  2. Breen, W., et al. (2020, November 1). Adjuvant Radiation Therapy for Pleural Mesothelioma after Extrapleural Pneumonectomy (EPP) or Pleurectomy and Decortication (P+D). International Journal of Radiation Oncology. Retrieved May 23, 2024, from
  3. Cao, C., D. Tian, J. Park, J. Allan, K.A. Pataky, T.D. Yan, (February 2014). A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma. Retrieved May 23, 2024, from
  4. Casiraghi M., et al. Induction chemotherapy, extrapleural pneumonectomy and adjuvant radiotherapy for malignant pleural mesothelioma. Eur J Cardiothorac Surg. 2017 Nov 1;52(5):975-981. Retrieved May 23, 2024, from
  5. Cleveland Clinic Health Essentials. (2021, May 18). Scheduled for surgery? Five ways to prepare yourself. Retrieved May 23, 2024, from
  6. Danuzzo F, Maiorca S, Bonitta G, Nosotti M. Systematic Review and Meta-Analysis of Pleurectomy/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma. Journal of Clinical Medicine. 2022; 11(19):5544. Retrieved May 23, 2024, from
  7. General Thoracic Cardiovascular Surgery. (2014, March 19). Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma. Retrieved May 23, 2024, from
  8. Journal of Thoracic Disease. (2018, January 10). Surgery for malignant pleural mesothelioma: an international guidelines review. Retrieved May 23, 2024, from
  9. Journal of Thoracic Disease. (2019, March 11) Extrapleural pneumonectomy. Retrieved May 23, 2024, from
  10. Magouliotis, D.E., Zotos, PA., Rad, A.A. et al. Meta-analysis of survival after extrapleural pneumonectomy (EPP) versus pleurectomy/decortication (P/D) for malignant pleural mesothelioma in the context of macroscopic complete resection (MCR). Updates Surg 74, 1827–1837 (2022). Retrieved May 23, 2024, from
  11. University of California San Francisco Thoracic Surgery Department of Surgery. (n.d.). Extrapleural Pneumonectomy. Retrieved May 23, 2024, from
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